Clinical Challenge: Rash Around Mouth for One Year - MPR

Clinical Challenge: Rash Around Mouth for One Year

Slideshow

  • Slide

A 13-year-old boy presents with a chief complaint of a rash around his mouth, which has been present for approximately one year. There is occasionally a slight itching or burning associated with the rash.

The patient’s parents state that the boy is humiliated by his appearance and does not want to go to school because he is being teased. He has seen his primary-care doctor and was prescribed oral and topical acyclovir and then subsequently topical triamcinolone. He has no other past medical history, is up to date on all of his vaccines and has met all of his developmental milestones.

On exam there is a well-nourished well-developed Hispanic male who is slightly overweight. A full-body skin exam is significant only for erythematous papules and pustules with a slightly scaly base in a ring-like distribution around his lip vermillion.

Perioral dermatitis is a relatively common acneiform eruption that occurs most frequently in children and young women. The eruption consists of erythematous papules and pustules, which occur in a perioral, periocular and nasolabial distribution. The individual lesions often resolve leaving...

Submit your diagnosis to see full explanation.

Perioral dermatitis is a relatively common acneiform eruption that occurs most frequently in children and young women. The eruption consists of erythematous papules and pustules, which occur in a perioral, periocular and nasolabial distribution. The individual lesions often resolve leaving an erythematous and scaly base. Since the periocular skin may be involved, the term “periorificial dermatitis” is frequently employed to better represent the distribution. 

Perioral dermatitis is considered by some to be a variant of acne rosacea, as the two share similar histopathologic features. The most frequently identified cause is the use of moderate- to high-potency fluorinated topical corticosteroids. Patients may also have a history of inhaled (for asthma) or systemic (oral prednisone) corticosteroid use. However, a proportion of patients have no such relevant history.1, 2


Diagnosis                       

Diagnosis is based on the clinical appearance of papules, pustules and erythema in a perioral, and/or periocular and nasolabial distribution. A history of topical or inhaled corticosteroid use is supportive. Biopsy is rarely indicated.1, 2           

Treatment and prognosis

Untreated, periorificial dermatitis can last for months to years. The first step to treatment is discontinuing topical corticosteroids or protecting the skin from inhaled corticosteroids. Patients should be warned that there may be an initial exacerbation of the eruption upon discontinuation. 

Secondly, for patients older than 8 years, prescribing an oral antibiotic in the tetracycline class is highly effective, but must be continued for several months and then tapered to prevent a rebound flare. For younger children, in whom tetracyclines are contraindicated, oral erythromycin is administered in a similar manner. 1, 2 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

1. Bolognia J , Jorizzo JL, Rapini RP. “Chapter 38: Rosacea and Related Disorders.” Dermatology. 2008: Mosby/Elsevier; St. Louis, Mo.

2. James, WD, Berger TG, Elston DM, and Odom RB. “Chapter 13: Acne.” Andrews’ Diseases of the Skin: Clinical Dermatology. 2006: Saunders Elsevier; Philadelphia.